In this study, LHSs were surveyed to learn factors that motivate their work with the LHW-P. LHS motivating factors were analyzed into themes at the individual, community, and health system levels. Overall, these findings align with similar research on CHW motivation in LMICs. Motivating factors at the community and health system levels are supportive supervision, recognition, training, logistics, and salaries. At the individual level the motivating factors are family support, autonomy, and altruism. In this study, the role of supportive supervision in motivating LHSs was of particular interest, and was described by LHSs as an important motivating factor at the health system level. As this study was part of Nigraan, a larger health system implementation research project, we interpreted these findings in terms of how health system programs, such as the LHW-P, can use and respond to these motivating factors.
LHSs in this study are motivated by the support they receive from LHW-P coordinators and managers as well as the supervision they provide to LHWs. As recipients of supervision, LHSs desire appreciative and encouraging support from the ADC and other LHW-P management. They also seek respect from the LHWs they supervise and are motivated when they perform their duties well in the community. Supervision as a motivating factor is recognized in other studies [14, 16, 20, 35], but primarily from the vantage point of supervision recipients comparable to LHWs of the LHW-P who are not in supervisory positions. LHSs are CHWs in a supervisory role, so these findings add unique insight on ways supervisors are motivated. CHWs from studies in Malawi, Tanzania, and Zambia do not comment on supportive supervision style specifically, but are receptive to the tone and presence of supervision, candidly describing its motivating influence [14, 16, 20]. In Tanzania and Zambia, CHWs were motivated by supervision that facilitated their learning and skill development [14, 16]. However, many CHWs were demotivated by supervisors unwilling to teach, problem solve, or support their role in the community [14, 16, 20]. LHSs are in the unique position, as compared to other CHWs, of receiving supervision and providing supportive supervision. As recipients of supervision, LHSs are similar to CHWs in these studies, in that they are motivated when they receive support from their coordinators and managers that is encouraging and attentive to their work problems. However, in their position as providers of supportive supervision LHSs are motivated by their ability to motivate LHWs to perform well in their communities. LHSs try to motivate LHSs by giving them respect, offering encouragement, and providing advice and training. In return, LHSs are motivated when their LHWs give them respect, improve their performance, and are engaged with and accountable to the communities they serve. In order to better understand positive supervisory relationships in the context of CHW-P, perceptions of the recipients of supportive supervision, such as LHWs, should be explored for comparison with supervisor perspectives.
Training opportunities, such as those provided by Nigraan also motivated LHSs in this study. Similar to CHWs in other LMICs [14, 17–19, 36], LHSs desired training to gain knowledge and skills that can help their families and communities. For example, CHWs in Malawi gained confidence from training sessions because it strengthened their community contribution [20]. In the case of Nigraan, training in supervision and CCM of pneumonia and diarrhea motivated LHSs. Research into CHW perceptions of various teaching pedagogies may identify CHW-P training strategies most effective for knowledge uptake and transfer.
As with CHWs from sub-Saharan Africa and South Asia [11, 12, 14, 17, 18, 20], LHSs in this study were also motivated by gains in community respect and prestige sourced from their position. Additionally, LHSs were motivated by updates on Nigraan’s research progress and certificates of performance and participation presented at regularly scheduled meetings. This finding illustrates that gestures of appreciation and recognition from the LHW-P coordinators and managers have potential to motivate LHSs. Furthermore, as with CHWs in Zambia [16], LHSs desire career advancement opportunities. Therefore, creating avenues of promotion or recognition may be an effective way to retain LHSs and motivate their work with the LHW-P.
LHSs conveyed the importance of family approval in allowing their work with the LHW-P to continue. LHSs were fearful that their families would demand they resign from the LHW-P. Although they did not provide explanations for this disapproval, CHWs in regional neighbor Bangladesh described safety concerns, female mobility, and gender norms as reasons their families disapproved of their work [15, 17]. For CHWs in Tanzania, family support with domestic and farm work was crucial to their ability to work [14]. Reasons for and influence of family approval or disapproval can vary regionally, therefore attention should be given to ways CHW-P can respond to the concerns of family members so they support their female relatives working as CHWs.
LHSs in this study share the financial and logistical frustrations of CHWs in South Asia and sub-Saharan Africa, in that they feel underpaid and undersupplied by the LHW-P [11, 14, 16, 17]. In-depth interviews and focus group discussions with CHWs from rural Tanzania and Ghana reported that inadequate salaries are common reasons for resignation or dissatisfaction [11, 14]. In Bangladesh, CHWs signaled unmet financial expectations as demotivating and disappointing [12, 13, 15]. This point is further illuminated by CHWs deployed as part of a national strategy in Zambia, who reported being demotivated because stipends promised by the government were only partially delivered, or not at all [16]. As with LHSs, Zambian CHWs described how limited medical supplies discredited their work in communities. These findings are unsurprising [23], but nonetheless highlight important areas of improvement in the LHW-P.
Limitations
Although this study did not endeavor to generalize, a larger sample size would have gathered greater depth and understanding of LHS perceptions. However, this study surveyed LHSs in a district that closely reflects provincial and national level program infrastructure and functionality, so it is perceived that these findings would resonate with LHSs in other districts of the LHW-P. During data collection, surveys were administered to a group of LHSs, so it is possible that discussion amongst LHSs influenced their responses. However, Nigraan team members were present during the survey to keep discussion to a minimum and assure LHSs that their individual responses were valued, anonymous, and not scored. The rapport built between the Nigraan team and the LHS participants during the ongoing larger project was also important to LHSs feeling comfortable responding honestly to the survey.
